General Introduction to Depression

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General Introduction to Depression

• Public Health Detailers Training
• NYC Department of Health and Mental Hygiene
• Sandra Ramos, PhD
• Deputy Director, Office of Program Development
• Judy Stein, LMSW, MS
• Co-Director, NYC DOHMH Depression Initiative

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Outline

• What is depression
• Symptoms
• Causes
• Types
• Risk Factors
• Women
• Elderly
• Young Adults

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Outline

• Racial/Ethnic Disparities
• Psychosocial/Environmental Factors
• Burden
• Detailing Messages

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What Is Depression?

• A very common, highly treatable, medical illness.
• Affects physical, mental and emotional
  well-being.
• Affects basic, everyday activities like eating
  and sleeping.
• Affects how people think about things and feel
  about themselves.

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What is Depression?

• In contrast to the normal emotional experiences
  of sadness, loss, or passing mood states,
  clinical depression is persistent and can
  interfere significantly with an individual's
  ability to function.
• People with depressive illness cannot just pull
  themselves together and get over it.
• Depression often takes on a life of its own
  without treatment, symptoms can last months or
  even years.

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Symptoms of Depression

• Feeling sad, blue, or down in the dumps
• Loss of interest in things you usually enjoy
• Feeling slowed down or restless
• Having trouble sleeping or sleeping too much

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Symptoms of Depression

• Loss of energy or feeling tired all the time
• Having an increase or decrease in appetite or
  weight
• Having problems concentrating, thinking,
  remembering or making decisions
• Feeling worthless or guilty
• Having thoughts of death or suicide

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Symptoms of Depression

• People with Major Depression experience at least
  five of these symptoms all day, nearly every day,
  for at least 2 weeks.
• The symptoms cause clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.

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Causes of Depression

• Causes not known, but current theories include
• Genetic
• Runs in families
• However, depression can also occur in people who
  have no family history.
• Environmental
• A serious loss, difficult relationship, financial
  problem, or any stressful (unwelcome or even
  desired) change in life patterns can trigger a
  depressive episode.

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Causes of Depression

• Personality Characteristics
• low self-esteem, pessimistic world view, low
  stress tolerance
• Whether this represents a psychological
  predisposition or an early form of the illness is
  not clear.
• Biological
• Continues to be studied extensively
• Current thinking explores problems in brain
  functioning in the following areas Limbic
  system, neurotransmitters and neurons, hormones
  and the endocrine system

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Causes of Depression

• Combination
• a combination of genetic, psychological,
  environmental, and/ or biological factors may
  contribute to the onset of a depressive disorder.
  

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Forms of Depression

• Major Depression
• At least 5 of the 9 symptoms of depression
  present including either loss of
  interest/pleasure or depressed mood symptoms
  interfere with daily functioning
• Minor Depression
• Fewer symptoms than major depression with
  significant disability shorter duration than
  chronic depression

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Forms of Depression

• Bipolar Disorder
• Cycling mood changes with severe highs (mania)
  and severe lows (depression)
• Dysthymia
• Low grade chronic symptoms of depression that
  last for a minimum of 2 years

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Depression and Suicide

• Of those with MDD, close to 50 report feelings
  of wanting to die, 33 consider suicide and 8.8
  report a suicide attempt.
• More than 90 of those who commit suicide have a
  diagnosable psychiatric illness at the time of
  death, usually depression, alcohol abuse or both

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Who is at risk for Depression?

• Anyone is potentially at risk for a depressive
• illness. Yet, these groups are believed to be at
• higher risk
• Older adults
• Young adults
• Women, pregnant and post partum women
• Note women report depression about twice as
  often as men. This may result from a greater
  likelihood to discuss depression or to seek help.

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Depression in Women

• Depression is the second leading cause of
  disease-related disability among women
• 1 in 4 women will suffer from a Major Depressive
  Episode during the course of their lives as
  compared to 1 in 10 men.
• Women may be more likely to discuss depression or
  to seek help.
• Women of childbearing age are at increased risk
  for major depression
• Pregnancy and new motherhood may increase the
  risk of depressive episodes

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Depression in Older Adults

• Of the nearly 35 million Americans age 65 and
  older, an estimated 2 million have a depressive
  illness (major depressive disorder, dysthymic
  disorder, or bipolar disorder).
• Symptoms of clinical depression can be triggered
  by other chronic illnesses common in later life,
  such as Alzheimers disease, Parkinsons disease,
  heart disease, cancer and arthritis.
• Depression is one of the most common conditions
  associated with suicide in older adults.
• Individuals age 65 and older have highest rates
  of suicide
• High suicide rate among older people (85 and
  older) is largely accounted for by White men.

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Depression in Young Adults

• 10 of college students have been diagnosed with
  depression, including 13 of college women.
• Lifetime prevalence for MDE highest among young
  adults age 18-25 (10)
• Suicide is the third leading cause of death for
  those aged 15-24

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Additional Risk Factors for Depression

• Family or personal history of depression
• Current substance abuse problem
• A major life stressor or change in life events
  i.e. loss of a loved one or a job
• Chronic disease

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Depression in Racial/Ethnic Minorities

• Mental health needs of minority racial/ ethnic
  groups remain largely unmet .
• Certain groups have higher rates of major
  depression
• Native Americans
• Women (middle aged, separated or divorced,
  low-income)
• Mexican- American and white individuals
• Have significantly earlier onset of major
  depressive disorder compared with African
  Americans.

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Depression in Racial/Ethnic Minorities

• Latinos with self reported depression are less
  likely to
• receive any treatment for depression
• fill an antidepressant prescription
• receive adequate course of psychotherapy
• African American and Latinos are more likely than
  Whites to be under-diagnosed and under-treated
• Minorities are less likely than Whites to receive
  treatments that adhere to treatment guidelines

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Explanatory Factors

• Lack of insurance coverage
• Poor access to appropriate screening and early
  detection
• Tendency to attribute mental health problems to
  religious and other cultural belief systems
• Lack of access to receptive and culturally
  compatible providers

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Psychosocial/Environmental Factors

• Psychosocial health has been associated with
  mental health in general and with depression in
  particular
• Neighborhood social disorganization is associated
  with depressive symptoms,
• Living in socio-economically deprived areas is
  associated with depression. A recent study found
• 29 - 58 were more likely to report part 6
  month depression
• 36 - 64 were more likely to report lifetime
  depression

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Depression Burden

• Untreated depression causes distress, disability,
  and, most tragically suicide.
• Depressive disorders are associated with
  increased prevalence of chronic diseases (e.g.
  asthma, diabetes)
• Increased use of general medical services as well
  as costlier health services, such as Emergency
  Room and Inpatient.

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Depression Burden

• Patients who are depressed are more likely to
  engage in behaviors that contribute to poor
  health, such as smoking, limited or no exercise,
  poor eating habits and are likely to have greater
  difficulty managing their co-morbid conditions.
• ? Depressive disorders are projected to become
  the leading cause of disability and the second
  leading contributor to the global burden of
  disease by 2020
• US workers with depression cost employers an
  estimated 44 billion per year.

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Detailing Messages

• Primary care physicians can effectively detect
  and manage depression.
• Routinely screen for depression using a simple
  2-question tool (PHQ2)
• Depression can be treated! Medication and
  psychotherapy, alone or in combination, can help
  most patients.

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Detailing Messages

• Primary care physicians can effectively detect
  and manage depression.

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Detection of Depression Why Screen and Manage in
primary care?

• Primary care is the 1st line of defense To
  find people who may be depressed or at risk for
  depression who dont know it
• Screening for depression in the primary care
  setting improves detection rates
• US Preventative Service Task Force (USPSTF)
  recommends screening adults for depression in
  clinical practices that have systems in place for
  accurate diagnosis, effective treatment, and
  follow-up.
• Only 50 of those referred to specialty mental
  health practitioners complete more than one visit

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Detailing Messages

• Routinely screen for depression using a simple
  2-question tool (PHQ2)

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Depression Screening PHQ2

• A physician can simply and quickly screen for
  depression by asking 2 questions (PHQ2)
• During the past 2 weeks, have you been bothered
• by
• 1. little interest or pleasure in doing things?
• 2. feeling down, depressed, or hopeless?
• The PHQ-2 is a valid and practical tool for
  depression screening in busy medical settings.

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Detailing Messages

• Depression can be treated! Medication and
  psychotherapy, alone or in combination, can help
  most patients.

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Detailing Messages

• More than 80 of people with clinical depression
  can be successfully treated.
• Antidepressants are the 1st line treatment for
  moderate to severe depression
• About half of the moderate to severe episodes of
  depression will improve with antidepressant
  treatment
• A combination of pharmacotherapy and
  psychotherapy may improve treatment response ,
  reduce risk of relapse, enhance quality of life,
  and increase adherence to pharmacotherapy.